PAIN, RELAXATION, MINDFULNESS AND MEDITATION
A Literature Review
Dr Ian Gawler OAM, BVSc, MCounsHS November 2020

A personal experience with pain

Before diving into the research, please be clear; people can have very different experiences with pain. Growing up, I always seemed very sensitive to pain. Therefore, as an adult, to be able to experience a root canal treatment with a live tooth root and no local anaesthetic as non-hurtful came as a major breakthrough.

Reaching to this point took some mind training. It was provoked by the extremely painful experience of having my right leg amputated through the hip due to bone cancer, and the knowledge that bone cancer if it was to recur (which it did) is regarded as one of the most painful of all cancer types.

Then came Dr Ainslie Meares and meditation. Dr Meares was a psychiatrist who had a special interest in pain management and a curious mind. He travelled widely visiting cultures that used mind control to better manage pain, and eventually came across meditation. His worldwide bestseller of 1967, Relief Without Drugs set out a way to use meditation to completely alter our relationship with pain and our perception of pain.

It is to Dr Meares I owe my own remarkable shift in pain management, and his approach informed the way I have been able to help others.

Personal experience helping others to manage their own pain

Having recovered from Osteo-genic sarcoma (bone cancer) secondaries in 1978, I began a lifestyle-based cancer self-help program in 1981. The program was set out in my 1984 book You Can Conquer Cancer (still in print) and pain management was a key part of the program.

Over decades I have been fortunate to observe many, many people transform their own experience of pain. In some this has just made life a little easier, for others it has brought about major relief and the capacity to return to a more normal life.

The techniques

We need to be clear here. Many people who meditate regularly find they seem to manage pain more easily. Pain does not seem so acute, they become more tolerant of it, it does not adversely affect their lives so much. So simply meditating on its own is helpful.

However, the real benefits seem to come from actually training in pain management. How to do this is fully set out in You Can Conquer Cancer, and covered more essentially in my latest book on meditation Blue Sky Mind.

The techniques most people have found most helpful are included on the Allevi8 App. They are the basic, but very effectiveDaily Meditation practice, along with the more specific Pain Relief and Finding Peace exercises. There is also an introductory video I recorded.

If you are experiencing pain currently, it is important to know that relief is possible and I do wish you find help like I was so fortunate to do.

Incidence of pain

Chronic pain is common in Australia. One in 5 Australians aged 45 and over are living with persistent, ongoing pain. Chronic pain affects 1 in 3 adults in the USA. This pain can be disabling and stressful, making it hard for a person to work and do the things they enjoy. In 2018, chronic pain cost an estimated $139 billion in Australia, mostly through reduced quality of life and productivity losses.

The definition of pain

The International Association for the Study of Pain (IASP) revised its definition of pain in July 2020. This definition followed lengthy consultation and is widely accepted.

Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

This definition is expanded upon by the addition of six key Notes and the etymology of the word pain for further valuable context.

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Definition reference : Raja, Srinivasa N et al. International Association for the Study of Pain definition of pain: concepts, challenges, and compromises, PAIN: September 2020 - Volume 161 - Issue 9 - p 1976-1982

LINK https://journals.lww.com/pain/Abstract/2020/09000/The_revised_International_Association_for_the.6.aspx

Acute Pain

Pain that is acute, or short-term, is a response to damaged tissue and usually disappears once the tissue has healed.

Chronic Pain

Chronic pain is pain that lasts beyond normal healing time after injury or illness—generally 3 to 6 months. It is a common and complex condition, and the pain experienced can be anything from mild to severe. The defining characteristic of chronic pain is that it is ongoing and experienced on most days of the week. Chronic pain can result from injury, surgery, musculoskeletal conditions such as arthritis, or other medical conditions such as cancer, endometriosis or migraines. In some cases, there may be no apparent physical cause.

Chronic pain is more complex than acute pain and may result from damage to body tissue from an acute or chronic condition, or changes in the nerves or nervous system that result in the nerves continuing to signal pain after the original condition has healed.

Chronic pain can affect a person’s use of health care and ability to work, exercise and socialise. People with chronic pain are more likely than those without chronic pain to experience mental health conditions, including depression, anxiety, sleep disturbance and fatigue.

There may also be a two-way relationship between chronic pain and mental health disorders. Many people with chronic pain report psychological distress, and psychological symptoms may be associated with increased risk of chronic pain.

Chronic Pain in Australia, Australian Institute of Health and Welfare, 2020

LINK https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf.aspx?inline=true

Clearly, chronic pain is a major public health problem. Based on the alarming prevalence, enormous cost to society, and current limitations with conventional treatment approaches, the Institute of Medicine has called for a cultural transformation in the way pain is viewed and treated.

Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. PMID: 22553896.

LINK https://pubmed.ncbi.nlm.nih.gov/22553896/

THE RESEARCH into

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elaxation, mindfulness, meditation and pain – a summary

In simple terms, mindfulness meditation does offer a fundamental shift in view and a path of transformation in its own right. While studies have provided varying results, there is now ample evidence mindfulness meditation-based interventions can have a positive impact on individuals suffering from chronic pain of various kinds. By teaching the core self-regulation skills of bare attention, detached awareness, self-compassion, and uncoupling, mindfulness meditation offers a new way of seeing, and a new way of being, which holds potential to relieve pain, reduce suffering, and restore wholeness, hope, and functionality.

Again, speaking personally, the results observed in our own groups seem way more consistent and strong than those reported in the literature, and this reflects why I am so confident in advocating the techniques on Allevi8. Significantly, in both my personal and clinical experience, the Progressive Muscle Relaxation technique (Deep Relaxation on Allevi8) plays a significant part in long-term effective pain relief and is well worth practicing regularly.

KEY RESEARCH STUDIES EXAMINING RELAXATION, MINDFULNESS, MEDITATION AND PAIN

This is not intended as an exhaustive review, rather a good, representative sample of the published research in this field, with a number of meta-analyses are included.

EARLY RESEARCH

1. Mindfulness alleviates chronic pain syndromes

Early research found mindfulness meditation to be associated with a significant reduction in pain, fatigue, and sleeplessness along with improved function, mood and general health for people with chronic pain syndromes.

Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985 Jun;8(2):163-90.

LINK https://pubmed.ncbi.nlm.nih.gov/3897551/

Singh BB, Berman BM, Hadhazy VA, Creamer P. A pilot study of cognitive behavioral therapy in fibromyalgia. Altern Ther Health Med. 1998 Mar;4(2):67-70.

LINK https://pubmed.ncbi.nlm.nih.gov/9682514/

Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibromyalgia: a randomized controlled trial. J Rheumatol. 2003 Oct;30(10):2257-62.

LINK https://pubmed.ncbi.nlm.nih.gov/14528526/

2. Deep Relaxation and pain relief

This review reported positive findings for relaxation interventions in 8 of the 15 studies reviewed. The most frequently supported technique was Progressive Muscle Relaxation (PMR – and the basis of the Deep Relaxation exercise in Allevi8), particularly for arthritis pain.

Most of the studies reviewed had weaknesses in methodology, which limited the ability to draw conclusions about interventions. The authors recommended further research is needed to confirm positive findings related to PMR, jaw relaxation, and systematic relaxation, to address questions related to the dose-response relationship and the individual differences that might influence response to relaxation interventions. These and other relaxation techniques require testing in carefully designed and conducted trials.

Kwekkeboom K, Gretarsdottir E. Systematic review of relaxation intervention for pain. J Nurs Scholarsh. 2006;38: 269–277.

LINK https://pubmed.ncbi.nlm.nih.gov/17044345/

RECENTLY PUBLISHED STUDIES

1. Mindfulness and Pain – a meta-analysis

This systematic review was undertaken to describe the effectiveness of mindfulness interventions for pain and its underlying pathophysiologic mechanisms. Six studies met the search criteria. These studies tested several types of intervention including mindfulness-based stress reduction, mindfulness-based cognitive therapy, meditation with massage, and mindful awareness practices.

Study outcomes include reduced pain severity, anxiety, stress, depression, and improved quality of life.

Ngamkham S, Holden JE, Smith EL. A Systematic Review: Mindfulness Intervention for Cancer-Related Pain. Asia Pac J Oncol Nurs. 2019;6(2):161-169.

LINK https://pubmed.ncbi.nlm.nih.gov/30931361/

2. Mindfulness and chronic pain – a systematic review

In this review of both randomized and nonrandomized controlled trials of mindfulness -based interventions (MBI) for chronic pain, the authors note MBIs were generally associated with greater psychological and physical symptom reduction than wait-list control groups (i.e., comparing MBI to no treatment at all), but did not consistently demonstrate greater efficacy when compared to active control groups (i.e., comparing MBI to alternative treatments). However, a preponderance of evidence suggests MBIs are effective for reducing both physical and psychological symptoms among individuals with chronic pain.

Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: a systematic review of the evidence. J Altern Complement Med. 2011 Jan;17(1):83-93.

LINK https://pubmed.ncbi.nlm.nih.gov/21265650/

3. Mindfulness meditation and pain management - is it effective? A major review

This study from Johns Hopkins University’s Evidence-based Practice Center in Baltimore, examined 18,753 studies. Only randomized clinical trials with active controls for placebo effects were selected. Next the strength of evidence was graded using risk of bias, precision, directness, and consistency, and then the group determined the magnitude and direction of effect by calculating the relative difference between groups in change from baseline. Forty seven trials (with 3515 participants) met the criteria to be included in the final analysis.

The results? Mindfulness meditation programs had moderate evidence of reduced anxiety at 3-6 months, depression at 8 weeks and at 3-6 months, and pain; and low evidence of improved stress/distress and mental health-related quality of life.

Among the 9 RCTs evaluating the effect on pain, moderate evidence was found that mindfulness-based stress reduction reduces pain severity to a small degree when compared with a nonspecific active control.

It is worth noting most studies only evaluated short-term effects, and there may well be significant differences between different techniques and different times people spend practicing these techniques.

Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.

Goyal, M et al. JAMA Intern Med. 2014 Mar;174(3):357-68.

LINK https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1809754

4. Online mindfulness program effective for pain relief

This study investigated 99 people with chronic pain. Those who attended in person, and those who used videoconferencing achieved similar gains in mental health and pain catastrophizing levels relative to controls. However, those who attended in person obtained significantly higher scores on the physical dimension of quality of life and lower usual-pain ratings than the online group. The results suggest that videoconferencing is an effective mode of delivery for the Mindfulness course and may represent a new way of helping chronic pain patients.

Gardner-Nix J, Backman S, Barbati J, Grummitt J. Evaluating distance education of a mindfulness-based meditation programme for chronic pain management. J Telemed Telecare. 2008;14(2):88-92.

LINK https://pubmed.ncbi.nlm.nih.gov/18348755/

5. Mindfulness and pain relief – a meta-analysis

Researchers reviewed more than 200 studies of mindfulness among healthy people and amongst other benefits, found mindfulness can help treat people with specific problems including pain. For example, mindfulness may reduce pain, fatigue and stress in people with chronic pain.

Mindfulness meditation: A research-proven way to reduce stress. Mindfulness meditation can improve both mental and physical health. Creswell JD and Khoury B. American Psychological Association website, 2019

LINK https://www.apa.org/topics/mindfulness-meditation

6.

Mindfulness does reduce pain intensity

This review examined articles published from 1960 to 2010. Only studies providing detailed results on change in pain intensity ratings were included.

Sixteen studies were included in this review (eight uncontrolled and eight controlled trials). In most studies (10 of 16), there was significantly decreased pain intensity in the MBI group. Findings were more consistently positive for samples limited to clinical pain (9 of 11). In addition, most controlled trials (6 of 8) reveal higher reductions in pain intensity for MBIs compared with control groups. Results from follow-up assessments reveal that reductions in pain intensity were generally well maintained. The authors concluded MBIs do decrease the intensity of pain for chronic pain patients.

Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity ? A critical review of the literature. Pain Med. 2013;14: 230–242. pmid:23240921

LINK https://pubmed.ncbi.nlm.nih.gov/23240921/

7. Acceptance, mindfulness and chronic pain – a meta-analysis

This meta-analysis examined 25 Randomised Controlled Trials totalling 1285 patients with chronic pain that compared acceptance and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up.

Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KMG. Acceptance- and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review. Cogn Behav Ther. 2016;45: 5–31. pmid:26818413

LINK https://pubmed.ncbi.nlm.nih.gov/26818413/

CONCLUSION

There is a solid evidence base for deep relaxation, mindfulness and meditation being used to help people alleviate their experience of pain.